Term
| A nurse is caring for a weak client with a compromised immune system. The client is unable to independently change positions while in bed. What nursing interventions should the nurse include in the plan of care to prevent skin breakdown? Select all that apply. |
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Definition
Turn and re-position every two hours.
Support boney prominences with pillows.
Elicit nutritional support from the dietician. |
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Term
| A nurse is caring for a client with a pressure ulcer on the right heel near two o’clock. The wound is 4.3 cm in length, 3.2 cm in width, and .5 cm in depth. A moderate amount of yellow exudate is present with foul odor. How should the nurse document the assessment findings? |
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Definition
| Right heel wound: located at two o’clock; measures 4.3cm x 3.2cm x .5cm; foul, moderate, yellow exudate noted. |
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Term
| The nurse is caring for a client who is being treated for herpes zoster. The client is being treated every four hours for pain. The client rates pain as 8/10. The healthcare provider ordered 200 mg of intravenous acyclovir (Zovirax) twice per day. The client remains afebrile. Which nursing diagnosis takes priority for this client? |
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Definition
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Term
| The nurse is caring for a client with vesicles on the left lateral thorax. The client is complaining of severe pain in this area. Based on the assessment, what precautions should the nurse employ? |
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Definition
| Place the client on contact precautions, in a private room. |
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Term
| You are caring for an 80 year-old immobilized client with pneumonia. The client consumes 50% of breakfast, 30% of lunch, and 10 % of supper. As you assess the client’s skin, you observe a reddened area on the client’s sacrum. Which nursing diagnosis should you address first? |
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Definition
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Term
| A client is being treated for a decubitus ulcer on the left hip. Which indication demonstrates the greatest improvement in wound status? |
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Definition
| A decrease in diameter to 2cm x 2cm x 1 cm |
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Term
| The nurse assesses a foul smelling pressure wound on a client’s sacrum which extends into the muscle and contains a large amount of purulent exudates. Thirty percent (30%) of the wound is covered by a black eschar. How should the nurse interpret these findings? |
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Definition
| The wound is unstageable due to the black eschar present. |
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Term
| Which of the following the clients is most likely to develop skin cancer? |
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Definition
| A female client with radiation burns |
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Term
| A nurse is caring for a client with malignant melanoma. The client comments, “I feel helpless, and useless. I’m afraid my life will end.” Based on the client’s comments, which nursing diagnosis should the nurse add to the plan of care? |
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Definition
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Term
| What should the nurse include in the plan designed to teach the client how to prevent skin cancer. Select all that apply. |
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Definition
Minimize exposure to sunlight.
Apply sunscreen with adequate protection factor.
Wear a hat and sunglasses while out in the sun. |
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Term
| What pre-operative teaching should be integrated in the plan for a client who will receive a rhytidectomy to remove facial wrinkles. What pre-operative teaching should be integrated in the teaching plan? Select all that apply. |
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Definition
Desanitizing scalp hair three times the night before surgery
Cleansing facial skin the morning before surgery with antibacterial soap
Avoiding aspirin and any blood thinning agents |
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Term
| A nurse is caring for a client who takes oral minoxidil (Loniten) to treat hypertension. The client is experiencing hirsutism. A nursing diagnosis of Disturbed Body Image r/t excessive facial hair was added to the plan of care. Which statement by the client indicates effective coping? |
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Definition
| “I know a side effect of the medication is excessive body hair.” |
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